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Vascular Surgery > Chap 108-109 Aorto-iliac Dz > Flashcards

Chap 108-109 Aorto-iliac Dz Flashcards

2
Q

What are symptoms of AI dz?

A

Claudication (calf, thigh, butt)
embolism (saddle or blue toe syndrome)
Erectile dysfunction

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3
Q

What collateral network supplies distal to AI dz?

why are the collaterals important?

A

lumbar and hypogastric feeding vessles connect to circumflex iliac, hypogastric, femoral and profunda recipients

in extreme, IMA to inferior epigastric and
SMA to IMA and
hemorrhoidal artery via arc of Riolan and meadering mesenteric artery

prevent CLI, main presentation in claudication

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4
Q

What are signs and symptoms of blue toe syndrome?

A

palpable pulses with patchy ischemia (livedo) but distal gangrene can occur

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5
Q

What is Leriche syndrome?

A

Terminal aortic occlusion

Thigh, hip, buttock claudication, atrophy of leg muscles, impotence, decreased femoral pulses

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6
Q

What is small aortic syndrome or hypoplastic aortic syndrome?
What is life expectancy?
Where is plaque?

A

Isolated AI in usually younger females, usually smokers
normal
posterior plaque prox or at bifurcation

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7
Q

What are pullback pressure in AI?

A

Pull back pressure 5-10mmhg at rest or change in systolic pressure greater then 15% indicates dz warranting revasc

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8
Q

What are indications for surgery?

A

disabling claudication
tissue loss
ischemic rest pain

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9
Q

What is natural history of claudicants in AI?

A

1%/year limb loss
5%/year mortality
20-30% require OR in 5 years

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10
Q

What % of AI have CAD?

A

nearly 50%

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11
Q

What are repair techniques for AI?

A 
endarterectomy
Aorto-bifem
Fem-Fem
Ax-fem
Obturator bypass
throaci/supra-celiac- fem bypass
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12
Q

When is endarterectomy best suited?

A

Small arteries
Want to avoid prosthetic graft
Erectile dysfunction as may improved hypogastric perfusion
Best for focal stenosis otherwise not usually done

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13
Q

Advantages to End-end in aortobifem?

A

Possible better hemodynamics, less flow turbulence
Less rate of pseudoaneurysm
Close peritoneum over graft
With concomitant aneurismal disease should to end-end

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14
Q

Advantages to end-side in aortobifem?

A

Preserve IMA
Preserve flow hypogastrics
Less erectile dysfunction, paraplegia secondary to cauda equina syndrome
Good if heavily calcified aorta

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15
Q

What is cauda equina?

what are symptoms?

A

damage to the cauda equina causes acute loss of function of the lumbar plexus, (nerve roots) of the spinal canal below the termination of the spinal cord. CES is a lower motor neuron lesion.

Urinary retention
decreased anal tone and consequent fecal incontinence;
sexual dysfunction;
saddle anesthesia;
bilateral (or unilateral) sciatic leg pain and weakness;
and absence of ankle reflex.

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16
Q

What dose of heparin do you give before clamping?

target ACT?

A

70-100units/kg

250-350 secs

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17
Q

Is there benefit of adjunctive profundoplasty in aortobifem?

A

May Improve long-term patency in AI bypasses

5year patency 88%

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18
Q

Advantages/disadvantages for external iliac anastomosis in AI bypass?

A

Good for hostile groin, obese, DM with intertriginous rash

More technically difficult and possible lower patency rates then to fem

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19
Q

when to consider inflow and outflow bypass?

A

tissue loss (appears no increase m&m)

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20
Q

how many patients have improvement of symptoms after ABF for AI?

A

80%

2/3 still have symptoms

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21
Q

When do you do concomittant SMA or Renal bypass?
what is mortality with ABF and ABF with SMA/renal recons?
what is symptom response rate?

A

If associated with the lesion repair
If thought to have reaversible on refractory hypertension or ischemic nephropathy

mortality 1-2% 5-6%(renal/SMA).

Favorable response to HTN 60-70%,
improvement in renal function 30%

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22
Q

what is 5 year patency for endart and ABFG in AI?
10 year patency?
moratlity rates?
10 survival?

A

95% and 85-90%
85-90% and 75-85% (older 95%, but <50yo 66%)
1%, 1-4%
isolated normal life expectency, multilevel disease 50%

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23
Q

patency difference between trans vs retro approach ABF?

PTFE vs Dacron

A

No

No

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24
Q

What are early complications and percentages ABF?

A 
Sexual dysfunction <5%
bowl ischemia 2%
MI 1-5%
death 1-4%
ALI 1-3%
bleeding 1-2%
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25
Q

where is bowel ischemia usually found after Bypass for AI?

how to avoid?

A

recto-sigmoid

preserve IMA, keep up perfusion

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26
Q

what are features of neurogenic claudication?

A

diffues deep aching,burning possible paresthesias from buttock to feet. relieved by sitting or beding over while walking. occurs with walking

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27
Q

What are common causes of IC?

A

SFA stenosis, athersclerosis, pop entrapment, ACD, chronic compartement syndrom, arteriris, thrombosis, FMD, coarctation

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28
Q

what are RF for claudication?

A

HTN, DM, metabolic syndrome, smoking, male, age, DLP, hyperhomocystenemia

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29
Q

What is natural history of IC?

A

10% deteriorate within one year then 2-3% per year to CLI
1% risk of major amputation per year
2-5% risk of cardiac death per year

70% angioplasty rates for 5 years

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30
Q

What is the natural history for CLI patients?

A

30% will lose leg in one year
if unconstructable 40% limb loss at 6 months
25% dead in one year
25% CLI resolved

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31
Q

What is included in hypercoag workup?

A 
thrombin/prothrombin times
activated partial thromboplastin time
protein S, protein C assays
factove V leidan asay
lupus anticoagulant assay
heparin induced plt antibodies
fibrinogen, plasminogen levels
ATIII activity
anticardiolipin antibody assay
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32
Q

How does hyperhomocysteine cause athero?

A

high level toxic to endothelium and reduce NO release, promote mSMC proliferation and arterial wall inflammation leading to athero

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33
Q

What is risk of surgery for PAD?

A

5% risk MI, CHF, death

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34
Q

What test to perfomr if has IC but palpable pulses?

A

exercise stress test
ABI at rest then walks 3.5km/hr on treadmill with 12% incline
if >20% decrease in ankle pressure for >3 minutes indicates vascular dz

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35
Q

What is the rutherford classification?

A

0 asympto normal
1 mild claudication completes treadmill test, but ankle pressure >50mmhg but at least 20mmhg lower then resting value
2 moderate caludication b/w catergories 1 and 3
3 severe claudication cannot complete standard teradmill exercise. AP after exercise <30
4 rest pain
5 ulcerations not exceeding digits
6 major tissue loss

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36
Q

what are features of a walking exercise for PAD?

A

treadmill or track walking, 35 mins porgressing to 50mins 35 times per week. treadmill incline should elicits IC within 3-5 mins

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37
Q

What drugs have evidence in IC?

A

cilostazol
naftidrofuryl
statin (supporting evidence)

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38
Q

what is cilastozol?

what is the evidence

A 
phosphodeisterase inhibitor
RCT, 50% increase in walking distance 
imporve QoL
CI in CHF
15% AE
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39
Q

What is the evidence for pentoxifylline?

A

MA questionable benefit

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40
Q

What was the BASIL trial?

what were findings of the trial?

A

RCT, angio vs open for severe limb ischemia
AFS primary end point

at 2 years surivival and AFS better in surgical arm, no difference at six months
if patient life expectancy >2 years then open

if attempt endo first then durability of subsequent open worse

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41
Q

What is the mortality with LE bypass?

wha are some complications?

A

2%
graft stenosis 20% in 1 year
major amp 5-10%
graft infection 1-3%

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42
Q

What are some scoring models for survival with LE intervention?

A

LEGES
Finnvasc
Prevent III
Basil

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43
Q

What are some indications for extra-anatomic bypass?

A 
high-risk laparotomy
hostile abdo
infected graft
AE fistula
groin sepsis
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44
Q

When is axem or fem-fem best suited?

when is obturator bypass best suited?

A

no endo option, high risk lap, hostile abdo or acute presentation

hostile groins

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45
Q

what is better unilat ilio fem or fem-fem for patency?

what about aorta-fem vs ilio fem?

A

unilat ilio-fem at ten years

no difference at ten years

46
Q

where is fem-fem tunneled?

A

prefascial plane

pre-peritoneal if thin or too fat, previsou surgery, radiation damage to skin

47
Q

What is the mortality periop, 3 yr survival, 5 yr patency for fem-fem?

A

<5%
70%
65%

48
Q

What features on duplex are concerning for graft failure?

A

peak systolic >300cm/sec inflow or <60cm/sec midgraft

49
Q

What size better for fem-fem? what amterial?

A

no difference

50
Q

what % have steal with fem-fem

A

3%

45% exercise induced

51
Q

Which side axillary artery to choose for ax-fem?

A

consider non-dominant
if will need future left chest surgery
if 10mmhg discrepency

52
Q

what is 3 year survival for ax-fem?
5 year patency?
3 yr limb salvage

A

35%
75% better in claudicants then CLI
70%

53
Q

What is normal resting flow in ax fem?

what flow indicates impending graft failure?

A

600-900 ml/min
300-400 ml.min each limb

<240ml.min in 6mm

54
Q

describe obturator bypass?

A 
donor artery exposed retroperitoneal via oblique lower quadrant incision (or trasnperitoneal)
dissect medial to external iliac vein and posterior to pubic ramus
obturator nerve (may injure) and artery perforate postolaterally
membrane must be opened sharply
55
Q

What are the 3 and 5 yr patency for obturator bypass?

A

75 and 60%

56
Q

What does the obturator nerve innervate?

A

sensory to medial thigh

motor of adductor muscles of LE

57
Q

What are features of throaco-fem surgery?

A

7-8th rib incision

tunnel graft retroperitoneally behind or anterior to kidney

58
Q

What are TASC A lesions for AI?

A

ui/bilat CIA

uni/bilat short <3cm EIA

59
Q

Waht are TASC B lesions for AI?

A

short infrarenal aorta
uni CIA occlusion
single or multiple (3-10 cm) isolated EIA
uni isolated EIA occlusion

60
Q

What are TASC C lesions for AI?

A 
bilat CIA occlusion
bilat isolated EIA stenosis (3-10cm)
unilat EIA stenosis into CFA
unilat EIA occlusion origin of CFA or iliac
heavily calcified uni EIA
61
Q

What are type D TASC lesions for AI?

A

infrarenal aortic occlusion
diffuse aort-iliac dz
diffuse stenosis of uni CIA, EIA, and CFA
bilat occlusion of EIA
iliac leasion in AAA that requires open surgery

62
Q

When should you consider preventative measure for constrast enduced nephropathy? what are they?

A

GFR <45ml/min if IV

volume
bicarb to alkalinize urine (MA shows benefit)
metformin can increase risk of AKI

63
Q

What is a significant pullback gradient?

A

10mmhg

>15% with papaverine

64
Q

what are re-entry devices?

A

outback

pioneer

65
Q

What are mechanical properties of balloon expandable vs self-expanding stents?

A 
balloon
better precision
high radio-opacity
high hoop strength
less flexible, premanently defromed, can become dislodged from balloon

self-expanding
greater felxibility

66
Q

what is the difference between selective stenting and angioplasty in AI?

A

RCT no difference with selective placement
20% will get stent reintervention and 20% in plasty alone will get reintervention

MA
better patency with primary stenting
reduces long term failure by 40% then plasty alone

67
Q

What are patency rates for TASC lesions for endo in AI dz?

for open?

A

10 yr A or B 70%
5 yr C or D 70%

5 yr 80% patency with 30% comps

68
Q

What are predictors of endovascular failure for AI dz?

what can improve patency?

A

EI dz (PPR 1 year 50%)
female
RI
CLI

covered grafts

69
Q

What is the definition of CLI?

A

persistent, recurring ischemic rest pain requiring opiate >2 weeks
AP <50mmhg

70
Q

What size vein for LE bypass?

A

3mm

71
Q

whats a linton patch?

A

when bypass comes of CFA endart anastomoses

72
Q

what is the patency of isolated popliteal target?

A

situational perfusion enhancement

5 yr patency 50%, secondary 75%

73
Q

What are graft options for LE bypass?

A 
SVG
LSV
superficial FV
arm vein
endarterectomized seg of SFA
cryopreserved vein
PTFE
ePTFE
contr vein
74
Q

What % of contra vein is used for future surgery?

A

20-25%

75
Q

What is the advantage of a vein cuff for LE bypass

A

may improve patency by 2-3 years

with cuff and PTFE 2 yr patency 50% vs 30%

76
Q

What is the difference between miller, taylor, st marys boot?

A

miller—rim of vein circum, then ptfe sewed to rim
taylor patch–patch on toe of anastomosis (half artery, half ptfe)
sta mary boot–rim of vei nthat folds around on itself vein then comes off the top

77
Q

What are correction rates for intra-op imaging for LE bypass?

A

arteriography 27%–may not see incomplete valve lysis

DUS 12% (psv >250)

78
Q 
What are patency rates of dacron vs ptfe for AK bypass?
HUV vs PTFE for AK?
PTFE cuff vs no cuff?
AK pop vein vs prothetic?
BK pop vein vs prosthetic?
infrapop vein vs prothetic?
A

1 yr 70% for both, 5 yr 50%

5 year 70 vs 40 (but some studies show not difference)

AK no diff, 1 yr 80%
BK 80 vs 65% 1 yr

60 vs 40% no signif

75 vs 55

70 vs 15%

79
Q

What is the benefit of warfarin therapy for infr-inguinal bypass?
insitu vs reversed?

A

warfarin benefited prothetic graft patency but at double bleeding complications

no difference

80
Q

what is a schedule for post-op graft surveillance?

what is the benefit of graft surveillance

A

4week
3 month x 1 year
6month x 2 yr
then yearly

improves patency by 15%

81
Q

what are duplex criteria for impending infrainguinal graft failure?

A

velocity >300cm/s
velocity ratio >3.5-4
drop in ABI 0.15
prophylactic repair

82
Q

what are causes of early graft failure?

A

early

anastomotic, clamp defect, valve defect, poor quality conduit, inadequate outflow

83
Q

What are techniques for treating stenosis or late occlusion?

A

patch, interposition, valve excision, plasty, anastomotic translocation

thrombectomy, lysis, redo with vein or prosthetic

84
Q

What are TASC A lesion for fempop?

A

single O <5cm

single s <10

85
Q

What are TASC B for fempop?

A 
multiple stenosis or collusion each <5cm
SS/O SFA <15
S/M lesions with no continuous runoff
Heavily calcified occlusion <5
single pop stenosis
86
Q

What are TASC C lesions for fempop?

A

multiple stenosis or occlusions total >15cm

recurrent stenosis or occlusion after 2 endo attempts

87
Q

what are Tasc D lesions for fem pop?

A

CTO of CFA/SFA

CTO of pop and prox trifurcation

88
Q

What are TASC A lesion for infrapop?

A

singel stenosis <1cm in tibials

89
Q

What are TASC B lesions for infrapop?

A

multiple stenosis of tibials each <1cm at trifurcation

short tibial stenosis with fempop PTA

90
Q

What are TASC C lesions for infrapop?

A

stenosis 1-4cm
occlusions 1.2 cm of tibials
extensive stenosis of trifurcation

91
Q

What are TASC D lesions for infrapop?

A

tibial occlusion >2cm

diffusely dz tibials

92
Q

What are determinants of succes in endovascular?

A

improvement in at leas one rutherford and ABI increase >0.15

absence of stenosis <200

93
Q

What are favorable characteristics for endovascular therapy?

A

proximal location
stenosis
short stenosis length
focal stenosis

single level dz
normal runoff

male
low comorbidities

IC
primary attemot

no residual stenosis or dissection
robust hemodyn response

94
Q

What is patency difference for lesion > or < then 2 cm?
focal vs multifocal?
good vs poor runoff?

A

5 yr 75% vs 50%
70% vs 20%
50 vs 30%

95
Q

What are 1,2,3 year success rates for endo in LE for endo vs open?

A

40, 20, 10 endo

85, 70, 70 open

96
Q 
How successful is angioplasty for fempop dz?
angio vs bypass?
angio vs stenting?
DES?
DCB vs POBA?
A

3 yr PP for stenosis in IC 60%
occlusion in IC 50%
stenosis in CLI 45%
occlusion in CLI 30%

BASIL, if lives >2 years open better

lesion greater then 5cm benefit from primary stenting

sirocco II failed to show improvement with DES for restenosis

DCB better at 6 months

97
Q

What is patency of angio for infrapop?

difference in angio vs stenting?

A

1yr 75%
3yr 60%

no difference

98
Q

wha is patency for laser atherrectomy?

A

1 yr 75%

99
Q

What is benefit of DES in infrapop endo?

A

3 yrs everolimus had higher PP then BMS 30 vs 20

100
Q

What is plasty/stenting surveillance?

A

ABI, PVR, Duplex

1,3,6,9,12 months then yearly

101
Q

what is patency of CFA steting?

A

3 yr patency 80%, surgery recommended

102
Q

What is endo not indicated for PFA?

A

usually not suitable because of ostial, bifurcation and diffuse

103
Q

What are cholesterol targets for PAD?
BP?
HbgA1C

A

sympto/asympto PAd LDL 100mg/dL
PAD and vascular dz in other beds 70mg/dL
<7%

104
Q

What medications should PAD patients be on, TASC?

A

ASA
beta-blocker peri-op
cilostazol first line for relief of claudication

105
Q

What is an alternative way to test for IC if ABI unreliable?

A

treadmill test
active pedal flexion
inflate cuff for 3-5 minutes, this produces reactive hyperaemia, measure pressure 30sec after deflating cuff

106
Q

What is critical TcPO2 level?

A

<30mmhg

107
Q

What are the principles of ulcer management?

A

restoration of perfusion
local ulcer and pressure relief
treatment of infection
diabetic control

108
Q

What are the treatment of choice for different TASC lesions for AI or fempop?

A

TASC A endo
TASC D open
TASC B endo preferred
TASC C open preferred if good risk

109
Q

What is 5 yr latency for ABF?

is it better then endo?

A

70% in CLI
80% in IC
better ing term latency but higher risk

Vascular Surgery (53 decks)

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